UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 762-vii

HOUSE OF COMMONS

ORAL EVIDENCE

TAKEN BEFORE THE

DEFENCE COMMITTEE

THE MILITARY COVENANT IN ACTION? PART 1: MILITARY CASUALTIES

WEDNESDAY 14 SEPTEMBER 2011

THE RT HON MR ANDREW ROBATHAN MP AND

THE RT HON MR SIMON BURNS MP

Evidence heard in Public

Questions 474 - 558

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Oral Evidence

Taken before the Defence Committee

on WEDNESDAY 14 SEPTEMBER 2011

Members present:

Mr James Arbuthnot (Chair)

Mr Julian Brazier

Thomas Docherty

Mr Jeffrey M. Donaldson

John Glen

Mr Mike Hancock

Mr Dai Havard

Mrs Madeleine Moon

Sandra Osborne

Bob Stewart

Ms Gisela Stuart

Examination of Witnesses

Witnesses: The right hon. Mr Andrew Robathan MP, Minister for Defence Personnel, Welfare and Veterans, Ministry of Defence and the right hon. Mr Simon Burns MP, Minister of State for Health, Department of Health, gave evidence.

Q474Chair: Welcome both of you, for the first time, to the Defence Committee. Military casualties are the subject today, as part of our series of inquiries into the military covenant in action. I would normally refer to you as Minister, but we cannot do that with two of you, so we shall say Andrew Robathan and Simon Burns.

I want to begin, Andrew Robathan, by asking you about the advances in treating and rehabilitating troops who have been wounded on operations. The main issue we wish to cover this afternoon is whether people who have been injured on operations on behalf of their country will be able to have an appropriately high level of care and sustained care for the rest of their lives, both under the Ministry of Defence and the National Health Service. We shall be coming to that issue time and again this afternoon but, starting with the Defence Medical Services, will they continue to have an appropriate level of resources to look after people who have been injured on operations?

Mr Robathan: If I can start with almost an opening statement, it will set the scene. Some of us in the room are old enough to think back 40 years when there was an entirely different set-up in the Defence Medical Services. You might remember the Cambridge Military hospital, Haslar and others, which for a number of reasons have closed. By the way, we think that is the right way forward; nobody is suggesting that we should go back to individual military hospitals.

Pace the Falkland Islands, we were in the cold war and medical services were changing. They had been set up during the second world war, and they were changing. Falklands war people might remember that Surgeon Commander Rick Holly had a field hospital at San Carlos and gained great credit for the work he did there. But that was a one-off, and it was not until the invasion of Iraq in 2003 and subsequently the war in Afghanistan that we have been in a position where we had casualties and injuries such as we sustain now. I shall not do it again, you will be pleased to know, but I wish to pay tribute to the last Government in that eight years ago it was certainly the case that the Defence Medical Services were not in the same position as they are now; we may discuss the Army recovery capability later. Although there was provision for field hospitals and so on, the casualties who have come back from Iraq and Afghanistan have completely changed the nature of what we have to deal with in the Defence Medical Services. That rather sets the scene.

Do we have the resources? I am tempted to say that we would always like more, but actually we do have the manpower to sustain the treatment that we are giving. We have the same work force needs, if I can put it that way, as the NHS, particularly in what is quite a new speciality-emergency medicine. I am not a clinician. I do not know if anybody here is, but emergency medicine is a new speciality and we would like more of it. But we are able to manage it. We certainly are managing, but we would like to increase it in one or two areas.

One way that we do manage the DMS and its resources is by the use of reservists. Some of you may have seen the Reserve deployment in the emergency field hospital at Bastion, which is very often staffed by reservists. I have seen it, and it is incredibly impressive.

Q475Chair: We have the resources now, but in a few years’ time we will withdraw from combat operations from Afghanistan. Will we have the resources then?

Mr Robathan: I can only speak for myself, but yes I think that we most certainly will. The tragic experience of Afghanistan and Iraq has taught us where our needs may be, and we are concentrating on those. There is certainly no intention to reduce the DMS; indeed, a project entitled DMS 2020 will determine the future size and shape of the Defence Medical Services post operations in Afghanistan. I think you have been given information about that already.

Q476Chair: Yes, we have. Thank you.

One of our deepest concerns as a Committee is that when the conflict in Afghanistan is out of people’s minds because it has moved into history, we will still have a large number of people with serious physical and mental injuries who may no longer be at the forefront of people’s sympathy in this country. That is one of the things that we want to ensure is properly dealt with so that they are treated as they fully deserve to be treated and money is laid aside now to cope with that. Simon Burns, do you have anything to add to what Andrew Robathan has said in relation to the Department of Health?

Mr Burns: On that narrow point, Chairman, I would add that both the Ministry of Defence and the Department of Health have recognised that, sadly, because of the nature of the injuries that have been sustained, they are something that will last individual members of the Armed Forces for the rest of their lives. That is why, given the commitments that we came into government with, the Prime Minister commissioned our colleague Dr Andrew Murrison to carry out two stand-alone reports. One, which was published late last year/early this year, dealt with the mental health aspects of Servicemen’s needs. The second one was on prosthetics, which is a crucial issue.

We have seen from the decisions that flowed from the Government-from DH and MoD-after the recommendations of the report on mental health that we accepted all the recommendations that Dr Murrison put forward. They are being implemented and will continue thereafter. Part of that will be a change in the attitude towards dealing with mental health problems in the Armed Forces. Similarly, the Department of Health is doing a considerable amount of work to change attitudes and the treatment of mental health in the wider community.

In addition, Dr Murrison has completed an inquiry, with recommendations, into prosthetics, dealing specifically with the concerns that you have raised with us, and that report has been presented to the Prime Minister. It is being looked at and in due course decisions will be taken and announced as to the best way forward.

Chair: No doubt we will be coming back to that report during the course of this evidence session.

Mr Robathan: May I add one thing? It is probably an appropriate time to say this because you asked what we were looking forward to after Afghanistan. I know that the Committee has been to Headley Court recently. I don’t think anybody here was on it but the Armed Forces Bill Committee also went. More than three quarters of the new cases in Headley Court last year were not related to operations at all. They were largely related to skeletal problems caused through training or through sport, which is an important part of training. Although you are concentrating on military casualties, the military sick are not just from operations.

Q477Chair: One final question. We will be coming back to all these things during the course of this afternoon. How is the Department of Health working with the Ministry of Defence to translate some of the advances that have been made into learning in the NHS?

Mr Burns: It would be fair to say that we accept that there is a considerable amount that the NHS can learn from the skills and techniques that have been developed following the military conflicts both in Iraq and Afghanistan. Let me give you an anecdotal piece of evidence. Someone from the NHS serving at Camp Bastion for three months will sadly, due to the circumstances, have more experience in trauma care than he or she would working in the NHS in England over a five to 10-year period. That is the scale of the challenge facing medical personnel, but it also shows the amount we can learn and how we can develop skills and techniques through unfortunate circumstances.

We are working extremely closely with the MoD to ensure that the NHS can capitalise fully on the learning and research that is coming out of both conflicts. What we have done to ensure that we do not lose out is create the National Institute of Health Research, which is a partnership that has been put in place to realise this. It is a partnership between the Department of Health and the Ministry of Defence in collaboration with University Hospitals Birmingham NHS Foundation Trust, which runs the Queen Elizabeth hospital in Birmingham. All partners are making a significant investment in ensuring that we can capitalise on what we are learning, to improve and enhance patient care.

Mr Robathan: It is a two-way thing, and when we are not in operations MoD doctors will be enhancing their trauma skills by working in NHS hospitals, as they already do. It is important to realise that. There is tremendous learning and cross-fertilisation that the NIHR in Birmingham is drawing on.

Q478Chair: That was the fundamental reason for closing the military hospitals, at Frimley Park for example, and I think that that was accepted by all parties.

Mr Robathan: Absolutely.

Q479Thomas Docherty: On the issue of learning and cross-fertilisation, the Committee went to the United States in April and went to the Walter Reed hospital. Can I ask the two Ministers what experience sharing you are doing with your US counterparts? Clearly, they have a greater volume of cases.

Mr Robathan: We work very closely together in Afghanistan, for a start, and indeed you will know that some Americans come into Bastion, depending on how things work. I am not entirely clear what cross-fertilisation we have had with the Americans, but there is a lot of clinical co-ordination. If you like, I will let you know exactly what we are doing when I have the illustrious Surgeon General who can tell me in rather more detail what exactly we are doing. We certainly co-operate. They are our closest allies and we work with them.

Mr Burns: What the Department of Health has done is to create a US-UK taskforce to help to share the learning, and they are meeting with me shortly. That is part of a range of things, of course, because what we are doing generally within the NHS to raise standards and make sure that we are world-class, is to look at all experiences of best practice, whether it be medical treatments or the way in which we organise the running of parts of the health service. That will have an international flavour, because we are looking at best practice elsewhere to see if we can pull things from it that would be applicable to enhancing and improving the quality and provision of care in the NHS. As I said in my earlier answer-I won’t repeat the whole background-the NIHR has been established as a body to capture and build upon research from the experiences in Afghanistan and Iraq, and it will also be a body that can look elsewhere to see if we can learn any lessons.

Mr Robathan: I have just been prompted, so rather than write to you let me just tell you that besides the US-UK Taskforce we have exchange medical officers, who go to the US Institution of Surgical Research in San Antonio. We regularly exchange papers. The co-ordination is pretty good between the two countries.

Q480Sandra Osborne: I have some questions for Andrew Robathan in relation to mental health problems as a result of operations. The King’s research has shown that there is an increased risk of PTSD, psychological distress and alcohol abuse if the harmony guidelines are exceeded. What account have you taken of those findings?

Mr Robathan: First, we are keen that the harmony guidelines are not exceeded, and I have the figures here. In fact, we are working very hard to ensure that they are not exceeded. In the Royal Navy, which of course includes the Royal Marines who are currently out there in 3 Commando Brigade, only 0.8% are breaching harmony guidelines at the moment. In the Army, 5% breach harmony guidelines, and in the RAF it is 2.6%. First, we want to stop that as far as we can, but sometimes it is difficult for all sorts of people who are moving units or whatever it may be. Furthermore, people sometimes volunteer to go out again with a different unit, for whatever reason.

I tread very carefully around the issue of mental health, because I am not a clinician and do not wish to pretend that I know more about mental health than I do. PTSD is a very complex situation. Apparently, approximately 4% of the general population are reckoned to have some form of PTSD and that is actually mirrored in the troops coming back from combat areas and indeed in the veterans who have left the Armed Forces. Actually, for those who have not been in combat, and indeed overall, the overall figure for the Armed Forces in the last three months is that only 0.3 people per thousand, which is 0.03%, are new referrals with PTSD. It is a very serious issue-very serious-and we must do all we can to help, but we should not make too much of it. As I say, I am not a clinician but I can see that those who have been in pretty traumatic situations do come back from operations, but PTSD is treatable and many of those with it are treated, and treated quite well.

Q481Sandra Osborne: Research has shown that those who have been in combat roles are more likely to suffer from mental heath problems. What account do you take of that in considering further deployments?

Mr Robathan: Somebody who is suffering from a mental health condition and is being treated will almost invariably not be deployed while they are undertaking treatment. I am pretty sure that is correct.

Q482Sandra Osborne: One of the major issues that we have heard about so far is that abuse of alcohol is quite a problem in the Armed Forces. What can be done to tackle that?

Mr Robathan: Alcohol dependence–alcoholism, in layman’s terms-is not actually common. The reasons for that are manifold. Of course, one is that if you spend six months in Afghanistan, you are dry for all but the two weeks of your R and R, so it is difficult to be dependent upon alcohol. We have not found any effect on operational effectiveness, partly because operational theatres are dry.

It is true that young men and-particularly interestingly-women in the Armed Forces drink quite considerably more than their civilian counterparts in the under-35s cohort. We hear a lot about binge drinking. It is partly because you put people together in a close-knit community. Certainly in the past, perhaps indeed when I was in the Army some 20 years ago, alcohol was more of a sort of bonding element of Armed Forces life. I understand that it is very much less so now and although people who serve now tell me that there is an issue, it is a problem that we do not underestimate. For instance, now you are never given a prize of alcohol for a sporting event. I must confess that in my larder at home there is a magnum of champagne that was presented to me for winning a competition between the House of Commons and the House of Lords. So we still do it here, if I can put it that way, but we do not do it in the Armed Forces, for the reasons that you have identified.

Q483 Sandra Osborne: Reservists suffer more on return from deployment. What can be done to prevent that?

Mr Robathan: I think that you came to Chilwell with the Armed Forces Bill Committee. First, the mental health of all those who serve really is a top priority. As I said, it is very difficult; you will know the Murrison Fighting Fit report, which I think has gone some way to addressing the problem. I do not think that I need to recap what was said about it.

Of course, there is an issue with demobilised reservists, because they are out of the community in which they have served and that in itself presents problems. Furthermore, they do not have immediate reference to an Armed Forces doctor-a military doctor.

It is very important that people’s GPs-civilian GPs-understand the impact that service might have had on an individual. For that reason, we are working with the Department of Health and the NHS to make GPs more aware of that issue. I should stress that the medical records of an individual reservist that are built up while he is serving are then transferred back to his home GP, so people should understand the issues, but there is slightly an education issue.

Q484Mrs Moon: When this Committee was in Washington, I took the opportunity to visit the new post-traumatic stress disorder and mental health unit opened by the Veterans agency. One of the issues they raised with me was the high incidence that they were finding of post-traumatic stress disorder in those who worked in the health services that were provided in theatre. Constant dealing with serious and traumatic injuries was causing an impact. Has any work been done within the Ministry of Defence and those services deployed by ourselves to provide medical services in theatre?

Mr Robathan: We have done a couple of small studies, but we certainly have not found any increase in PTSD among medical personnel. Have you seen the hospital in Camp Bastion?

Mrs Moon: I haven’t.

Mr Robathan: When you come out of the swirling wind, dust-storm area of the camp around Bastion and go into the camp base hospital, which is very busy, it is like entering a haven of quiet. I am not sure if that is why it is the case, but we have not found any evidence.

Q485Mrs Moon: I doubt the operating theatre is a haven of quiet. It is the actual experience of dealing with constant traumatic injuries that the Americans found was causing particular problems, and also for those in the Medevac units.

Mr Robathan: That is a very good point. I have to say we have had no experience of that-no evidence of it-but we will certainly look at that.

Q486Chair: If there is further information you discover on getting further inspiration, it will be helpful if you can write to us.

Mr Robathan: We will.

Q487Mr Hancock: Andrew, do you believe the Army is equipped to seek out and find people who are suffering from mental disorders, if such people have not referred the possibility of their having a mental health problem to their superiors or if they have not sought medical treatment? We were told in previous evidence sessions that to a certain extent the individual was reluctant to admit to having a mental health problem, so the onus is on the unit at various levels to recognise that there is a problem.

Mr Robathan: I think we have realised that there is the potential for big problems. You are absolutely right. Historically, there has been an attitude that one would not wish to confess to being stressed out or whatever it might be, because it would somehow undermine one’s credibility. But I think that has changed quite dramatically. There is something called TRiM-trauma risk management-within the chain of command and the unit, and people are actually checking up on their fellows.

The decompression that people undergo in Cyprus is pretty important. I can remember friends of mine who came back from Vietnam; they said they were in a fire fight one minute and six hours later walking around California. It was not a good way to be. I think that is important.

Q488Chair: How long is it?

Mr Robathan: It varies. I think it is normally three days. It is 36 hours minimum. I am afraid quite a lot of alcohol may be consumed, but it is an important calming-down business. Normalisation takes place and people understand that life is returning to normal.

On the reservists mentioned earlier, every reservist will be interviewed twice by the command structure and asked whether they have problems after being on operations. Those interviews, although they will not specifically be about mental health, will give people the opportunity to ask about and indeed volunteer any mental health problems.

Q489Mr Hancock: How effective would you say the military medical services are at dealing with mental health problems for Service personnel?

Mr Robathan: I think they are pretty effective. It is an improving picture, if I could put it that way. I go back to my point that once upon a time it was in some way a stigma to be thought to suffer PTSD or whatever. I do not think that is the case any more. I think they are good and we are learning on that. I go back to Dr Murrison’s Fighting Fit report. That is putting emphasis on mental health, which both in the Armed Forces and for veterans, is very important.

Q490Mr Hancock: Simon, is there any evidence of the military not being able to cope with mental health problems; that Service personnel are being treated in civilian facilities for mental health problems while still being in the military? Has there been an increase in that?

Mr Burns: The narrow answer to your question, Mr Hancock, is that I have seen no evidence of figures. The guiding principle has got to be that military personnel, like anyone else, must have access to the most appropriate care. That may well be in a military setting; it may be in an NHS hospital or unit. It depends on the individual circumstances.

Q491Mr Hancock: Back to you then, Andrew. What are the obstacles that might be in the way of Service personnel getting the right treatment for mental health problems?

Mr Robathan: They are not dissimilar issues from across the country or the general population. First, one has to understand that one has a problem and accept a diagnosis. This is where I tread very carefully. Secondly, military personnel often move around a hell of a lot, which is difficult. However, the chain of command is well aware of mental health issues these days and, dare I say, is much better than 20 years ago at making sure that people are not moved around. We would not wish to deploy people back on operations if they are being treated for a mental health problem, as I said earlier.

The obstacles? Treatment exists. As a result of Andrew Murrison’s report there are 30 community mental health nurses being deployed around the country, specifically for veterans and Service personnel. That is progress. I do not think the difficulties-apart from the style of life that people lead-are that much different from those of other people who suffer some trauma and PTSD, or whatever it might be.

Q492Mr Hancock: Simon, can you tell us about the arrangements with Staffordshire and Shropshire NHS, and how that is working?

Mr Burns: Yes. I do not know if you have been there. Generally, and rightly to my mind, Queen Elizabeth hospital is regarded as world-class. The new hospital that opened last summer has a dedicated military ward within the hospital, and the MoD works extremely closely with the chief executive and her staff, to ensure that those seriously injured continue to get the best possible care.

Q493Chair: This is about the Staffordshire and Shropshire trust.

Mr Burns: Sorry, Staffordshire, not Queen Elizabeth, I misheard.

Mr Hancock: These are the arrangements you set up with those two trusts.

Chair: Instead of with the Priory. This is the follow-on mental health.

Mr Hancock: From doing it privately.

Mr Robathan: Staffordshire and Shropshire is the lead trust for eight trusts. It carries on from what I was saying. We are working with the best NHS trusts for mental health. I think it has been going on for five years, which is significant of the change over the past decade. We are very happy with the way the contract has operated, and the level of care provided.

Q494Mr Hancock: But are you aware that people have to wait to get treatment there?

Mr Robathan: I am not aware of that.

Q495Mr Hancock: Could you write to the Committee to give some information about the amount of time people have to wait to get referred and treated?

Mr Robathan: I can give you the details on that, Mr Hancock, of course.

Q496Bob Stewart: Andrew Robathan, the Army recovery capability, which is excellent, is currently increasing in capacity, is it not? Is it going to make a capacity of 1,000 by the end of the year?

Mr Robathan: By April next year we are building it up to 1,000. We hope that will be a sufficient number. We believe that it will meet projected demand over a number of years, especially since, God willing, casualties will reduce in Afghanistan and because of our planned withdrawal from Afghanistan.

Q497Bob Stewart: At unit level, there is a natural dichotomy between wanting to look after your own once they are wounded and the requirement of the commander to have fully fit soldiers. What are your personal views on trying to manage the balance of having operational capability and soldiers wanting to stay with their units, and commanders wanting them to stay but having the problem of keeping his or her unit up to strength?

Mr Robathan: Are you talking about people being discharged?

Bob Stewart: Yes, I am.

Mr Robathan: The Army recovery capability, as you know, was put in motion by the last Administration, and that was a good step forward; it is going in the right direction entirely. It is designed to allow people who are at home or still in the unit, but probably at their home address, to be assessed and given every possible assistance, either to go back to their unit-even if they are disabled in some way or medically downgraded-or to move on to civilian life. I am keen that no one who is injured on operations, particularly those who are badly injured, leaves the Armed Forces, until when and if it is decided by both the individual concerned and the Armed Forces that that is the best way forward for them.

We all have to be realistic about the fact that everybody-two of them are having a conversation at the moment-leaves the Armed Forces in the end. Be it at the age of 25, 35 or 45, everyone will leave. But I am very keen that those who have suffered in the Service of their country are not compelled to leave until they are prepared and ready so to do. Does that answer the question?

Q498Bob Stewart: Yes, it does. What about a soldier who is badly wounded with fewer than five years’ Service? There are some thoughts that such a soldier gets less resettlement or is not automatically redirected to the Armed Forces compensation scheme. Does a soldier who is wounded with under five years’ Service get exactly the same conditions as one who has gone beyond five years?

Mr Robathan: I have not heard anyone suggest that they do not; I would be very surprised if they did not. If someone is badly injured, they are badly injured.

Q499Bob Stewart: I think that the Royal British Legion is suggesting that. It might be worth checking.

Mr Robathan: What is true is that people who are leaving the Armed Forces with fewer than four years’ Service get a less full resettlement package, but that would not apply in the case of someone who goes down the Army recovery capability road, which involves treatment, advice, and medical and other assistance.

Q500Bob Stewart: Would you mind if your officials checked that, because the Royal British Legion has suggested that that might not be the case?

Mr Robathan: I have some notes here that relate to that; it is regardless of how long people have been in Service. [Interruption.] That would be a waste of people’s time. If someone can come up with some evidence, I would be delighted to hear it, but I am pretty certain that all medical discharges get the full resettlement package. Certainly, I would be very unhappy, as a Minister, if I discovered that people who were badly injured in Afghanistan were not receiving proper treatment and resettlement on discharge.

Bob Stewart: I thought that would be your attitude. That is helpful.

Q501John Glen: Andrew Robathan, when someone is killed in operations, I believe that the Prime Minister writes to the bereaved family. Is there sufficient recognition for those who are seriously injured while on operations?

Mr Robathan: Yes. Are you suggesting that the Prime Minister should write to them as well?

Q502 John Glen: It is a matter I would like you to comment on.

Mr Robathan:I have seen some of the letters, and I thought that the last Prime Minister, Gordon Brown, the right hon. Member for Kirkcaldy and Cowdenbeath, was unreasonably criticised in some of the media for trying to do his best. When a bereaved family get a handwritten letter from the Prime Minister, they are in a very difficult time, but they must realise that actually-you and I write a hell of a lot of letters, if I can put it that way-to write a handwritten letter to an individual takes quite a lot of effort, and they are very decent letters. I have seen them. I think that writing to all individuals who are injured would be a superhuman task, and that does not reflect a lack of care, but just the fact that it is not really possible.

We see no reason to change the current approach. What I would say is that we recognise, both through the Armed Forces compensation scheme and through public recognition in the country as a whole, the sacrifice that many people have made in terms of limbs and health.

Chair: Simon Burns, you commented before on the working between the Queen Elizabeth hospital and the Ministry of Defence. We did not ask you questions about that because we visited the Queen Elizabeth hospital a couple of months ago, and we also went there in the previous Parliament. As before, we were extraordinarily impressed by the arrangements that exist and the quality of the care that is given to people who go through there. We felt we had a pretty good working knowledge of how that operates, which was why we did not ask you questions.

We are moving on to the topic that I said we would spend a lot of time on, which is the return to civilian life and what happens in the future.

Q503Mrs Moon: These questions are for both of you. We have had evidence from the Royal College of Physicians expressing grave concern about the availability of support for those who have life-changing injuries, and I will work through some issues that have been raised.

I am aware that we are waiting for the Murrison report on prostheses, but in terms of costs for a below-the-knee prosthesis, the replacement cost for one issued by Headley Court is £6,500, while one available through the NHS costs £350. Maintenance costs for an above-the-knee prosthesis are £2,000, on the purchase cost of £9,000, while the NHS cost is £1,000, with very little maintenance. What assurance can you give that those replacement, quality prostheses will be at that high level across the life of the individual who has suffered limb loss?

Mr Burns: You raise an extremely important issue that I know is also of grave concern to members of the Armed Forces who have sustained injuries. What I can say at this point is that we certainly recognise the problem. I understand, as many others do, the figures that you have just given, which illustrate the scale of the situation and what needs to be addressed.

I hope you will bear with me, because as was referred to earlier, Dr Murrison was commissioned by the Prime Minister, as his second inquiry and report, to look into this matter and all the issues flowing from it. He has completed a very detailed report, which is being considered. I am afraid that until decisions have been taken arising from his recommendations, there is not much I can say to help the Committee, in so far as I am not in a position at this stage to pre-announce or prejudge what decisions may flow from it. What I can give by way of assurance is that we fully recognise the situation and the challenges and we are giving extremely careful consideration to the report and its recommendations. As soon as it is appropriate and possible we will make announcements.

Q504Mrs Moon: Have you any idea of the time frame for those announcements?

Mr Burns: The only time frame I can give you at the moment that is realistic and not misleading is that we are anxious to do it as soon as possible without cutting any corners and rushing decisions.

Q505Mrs Moon: So are we talking six weeks or six months?

Mr Burns: Now you are trying to press me.

Mrs Moon: That’s my job.

Mr Burns: Indeed it is, but it is my job to avoid pitfalls or misleading anyone.

Mr Robathan: This is one of the biggest issues-you touched on it earlier, Chairman-long-term care. These very brave young men in their 20s who are going off to the north pole, sailing round the world or whatever-that is one thing, but how will they be looked after in their 40s and their 50s? There are various levels to it, but I think this Government, like the last Government, and any future Government will wish to look after those people properly. I think the military covenant will be one way in which people will say, "Hold on. These people deserve more, or deserve what you are giving them. So make sure you do give it to them." That is how we are looking at it. It is not just the report that is coming out. This is work in progress and we will need to make sure that we look after these people, which will be a long-term problem. I would stress that the numbers, fortunately, are not huge. For each individual it is a tragedy, but it is not a huge number of people, thank goodness.

Q506Mrs Moon: There are examples that the Royal College of Physicians has raised of concerns relating to tensions-

Mr Burns: Sorry?

Q507Mrs Moon: Concerns relating to tension have been raised by the Royal College of Physicians about injured military personnel in the prosthesis clinics being seen to be given a different level of service. How do you intend to deal with that? In particular, for example, they cite the situation where you might have someone from the police force or the fire brigade who has also been injured in Service. How are you building into the NHS recognition that there will be different tensions and difficulties when people are moving into NHS clinics and are going to be treated and seen alongside other civilians, if I can put it that way?

Mr Robathan: That is a huge question that we all need to be aware of, because in our desire, quite rightly, to recognise the sacrifice the Armed Forces are going through-the Service they have given to this country-there is likely to be an element of, dare I say it, discrimination or some form of jealousy. People say, "Why is this person getting better treatment than I am?" The police and fire services are doing it in the service of the community as well but I would say that those who put their lives on the line for their country are in a special place.

Mr Burns: I have certainly heard the same comments as you have about this. The challenge is that a modernised NHS has to be responsive to the needs of patients and it has to strive to be world-class and among the best in the world. So the challenge to the NHS is to make sure that we minimise the potential for jealousies by making sure that NHS patients get improved quality of service, quality of care and in this case we seek to improve the quality and standards of the prosthetics.

Q508Mr Brazier: That last answer leads me directly into what I wanted to ask. The understanding for some time now has been that war veterans were to take priority over other NHS patients for a variety of procedures. That was certainly the policy towards the end of the previous Government. Is that the policy of the current Government? If it is, in an increasingly fragmented structure-

Mr Burns: There is no fragmented structure.

Q509Mr Brazier: All right, in a devolved structure-a structure that I support-or in a structure where key decisions have rightly been devolved to a lower level, how are we ensuring that the understanding of that priority is promulgated?

Mr Burns: As an introductory remark, there is no question of fragmenting the NHS under its modernisation. We want local decisions at a local level, within a far more collaborative and integrated service, rather than a fragmented one. Having said that, there is no change. We recognise the debt that we owe as a society to those who are selflessly prepared to defend freedom and our country in difficult circumstances that can lead to horrendous injuries and, sadly, death. We believe, as the previous Government did, that former members of the Armed Services, if their medical condition is directly related to their Service in the Armed Forces, should have access to treatment-not in a crude way of automatically queue-jumping-that is clinically decided, because no one would want someone who was an absolute emergency to be pushed aside by a former member of the Armed Forces, least of all the individual concerned. We believe that, as long as it is subject to clinical necessity, where appropriate, veterans will be seen more quickly.

Q510Mr Brazier: Forgive me, but you have not answered my question. How are you ensuring that individual hospital trusts are doing that?

Mr Burns: Most of it is through the GPs, because it is the GPs who will make the referrals when a veteran goes to see them with whatever the medical complaint is. What we have been doing since we came to office is ensuring that GPs are aware of this requirement and are familiar with what it actually is, because in the past there has been some misunderstanding around it simply being for anyone who has been a soldier, regardless of the nature of their medical condition and how they got it. It applies only to a medical condition that is a result of them having served in the Armed Forces. They believed that they were automatically allowed to, to put it crudely, queue jump. That is not the system; it is more refined than that. Doctors have been contacted by the NHS to make them more aware and more understanding of the requirement. Veteran organisations have also been more active in explaining to former members of the Armed Services what they are entitled to, so that they can make use of it. There is a degree of ignorance of what it is on both sides, and we are seeking to address that.

Q511Mr Havard: The Royal College of Physicians talks-rightly so, because they are clinicians-about the potential of the individuals who come through the door, even though they are of a certain category. It says that there are "10 NHS patients of similar fitness and potential to each veteran." The size of the problem is significant. The provision for veterans in terms of these limbs and so on is at the smaller end of the scale. It is about the rest of the NHS population that are of a similar potential. There is a question about policemen, firemen, first responders and where you provide these definitions. Is some of this in Murrison’s report or is he restricting himself to Service people? If so, is there a start point for the obligation? There are still veterans from the second world war, the Falklands and other conflicts who are casualties not just because they have been in war theatre but because they have been damaged while in Service. There is a legacy problem as well as a current problem, and a potential forward planning problem.

Mr Burns: I do not want to be evasive. I will ask-

Mr Havard: Are they in the report or aren’t they?

Mr Burns: Can I just finish? I do not want to be evasive. I ask you to be patient. What you are trying to do, in an equally subtle way, is what your colleague was trying to do, which is to get me to answer a question that I am not in a position at this point to be able to answer.

Q512Mr Havard: I think you are able to answer it. It is either catered for in his terms of reference or it is not. If it is not, are you in the NHS in England, Scotland, Wales and Northern Ireland catering for it? Who is catering for it?

Mr Burns: The purpose of Dr Murrison’s report was to look into the whole issue of prosthetics and members and former members of the Armed Forces. His report, as I said, has been completed with a number of recommendations. It is being considered at the moment. As soon as it is appropriately possible to publish it and our decisions on the recommendations, we will do so, but it would be extremely unwise of me to be tempted by you to answer questions at this stage, when it is premature to provide answers.

Q513Mr Havard: Let me ask you the question the other way around, then. What are you in the NHS doing to address that problem? Never mind what Murrison is doing. What are you doing?

Mr Burns: Well, I will turn my answer around and say that what we are seeking to do in the NHS is to improve and enhance quality and standards of care so that we have a world-class National Health Service for all our citizens, free at the point of use for those eligible to use it.

Q514Mrs Moon: Can I take you to an area that perhaps you can talk about, brain injury? You have said that the priority treatment pathway is available to those injured during their Service life. If traumatic brain injury results from operations in theatre or during Service life, it will, on the whole, be identifiable while they are still within the Services, but traumatic brain injury can also not be identified for some years, and can become a serious issue affecting the person’s life and their capacity to cope. How are you going to ensure that brain injury whose cause relates back to service is also given priority treatment, when it may well appear some considerable time forward and may manifest itself through difficult and bizarre behaviour, mental health behaviour and criminal behaviour?

Mr Burns: The commitment applies not only when someone is serving in the Armed Forces but for the rest of their life, for any medical condition that arises as a result of when they were serving in the Armed Forces. The single-word answer to your question is yes. They will receive priority, with the provisos I gave in my earlier answer.

Q515Mrs Moon: I talked about difficult behaviour. It could appear as bizarre behaviour, often self-medicated through drugs and alcohol, that could lead someone into the mental health services or into the criminal justice system. How do you intend to track those manifestations of brain injury and ensure that they receive the appropriate medical services and are given the priority pathways? Are you going to track people through their post-service life so that they are flagged and receive the appropriate pathways of care?

Mr Robathan: If I might say briefly-of course, this will go to the NHS; I just need to say something. We are not going to track people as they leave the Armed Forces in general because about 20,000 people a year leave the Armed Forces, and not everybody would wish to get a telephone call saying, "How are you getting on?" What is important is that if an injury-a brain injury or whatever-is related to Service in the Armed forces, it is identified.

Q516Mrs Moon: And will be identified in the future.

Mr Robathan: Yes, and that is partly a question of education for GPs, although not everybody wishes to be known as an ex-Serviceman.

Mrs Moon: I appreciate that.

Mr Robathan: We get into issues of individual preference in life, but if a brain injury were to be identified as due to Service, that person would get preferential treatment-ought to get preferential treatment. I cannot swear blind that they all would, but they ought to.

Q517Chair: The impression that I have in relation to the question and in relation to the question asked by Julian Brazier is that the entire priority system really rests on the education of GPs issue. Is that right?

Mr Robathan: Not entirely, but to a large extent.

Q518Chair: Nevertheless, the priority issue is Government policy, and if the education of GPs matter appears not to be achieving the priority system that you clearly both wish to achieve, further steps will be taken to ensure that it is.

Mr Burns: Yes, quite clearly, because there is the commitment. We expect it to be honoured and if evidence emerges that it is not being honoured or too many GPs are unaware of it or not implementing it in the way that we believe it should be, we will have to look again to ensure that more is done to educate, familiarise and ensure that GPs are keeping to the commitments that we have given and the last Government gave for this.

Q519Chair: That is helpful. You wanted to add something-

Mr Burns: If that answer was helpful to that question, can I just say that the NHS, for the first year that someone leaves the Armed Forces, offers to follow up with individuals for the first year that they come out of the Armed Forces on a voluntary basis if the individuals want it because, as Andrew Robathan said in his answer, some people do not want-however beneficial or well meant-to be followed up.

Can I add just one other thing on the general issue of mental health and helping veterans who may have mental health problems at the time that they leave the Armed Forces or develop them later? A considerable amount of initiatives have been taken-a number from the recommendations of Andrew Murrison’s first report-to help to assist. For example, today the Big White Wall initiative is being launched. What is crucial there-we have not mentioned it in the course of the questions and answers so far-is that we must not simply think of members of the Armed Forces, vital and important as that is. There are also their families and relations who also need to be helped and given assistance, counselling, advice or whatever where appropriate. So I do not think that we should look at it in isolation, but remember the needs of family, partners etc.

Chair: We are going to come on to that in just a moment.

Mrs Moon: Can I go on to the social care costs?

Chair: Please do.

Q520 Mrs Moon: It is easy to look at the NHS costs, and the NHS is free at the point of delivery. But social care is not free at the point of delivery. The cheapest cost of social care, if you needed, say, four calls a day would be around £20,000 a year. There is also the question of means-testing for aids and adaptation of a person’s home through local authorities. Again, a basic cost for the provision of walk-in wetroom facilities is £20,000. Those are high-level costs. How will we ensure that local authorities have the capacity to meet that level of care and support and, in particular with aids and adaptation, to do them promptly? Can we have an assurance that, while the person remains in the military, the aids and adaptations will be undertaken in the military accommodation in which the person lives?

Mr Robathan: On your latter question, certainly they would be adapted, and indeed many homes are where necessary. Regarding the cost to local authorities, the truth is, as I have said before, that luckily there are not thousands of people-thank God-who are in this position, and the numbers are therefore relatively small. I don’t think it should throw over or destroy any local authority’s budget.

Q521Mrs Moon: Is there an expectation that people will pay for their social care costs out of their pension and compensation?

Mr Burns: Perhaps I could give you an answer about the whole social care issue, once someone leaves the Armed Forces. As you will know, there is going to be a social care White Paper next year, which will deal with the whole sensitive subject. It is not possible at the moment to anticipate what may or may not flow from that process, once there has been a White Paper, consultation and debate on the whole future of how social care is going to move forward.

Q522Mrs Moon: Can you tell us in relation to the present situation? Because if there is a White Paper next year, we are talking at least five years hence, possibly, before there is any change. Within the current legislation and scenario, are social care costs going to be met by the individual out of their compensation and pension commitments? That will disappear very rapidly.

Mr Robathan: That is an important issue that is being looked at. There have been incidences where people have been asked to contribute, I understand. I don’t have the details to back it up. Actually, what we advise is that the lump sum payment from an Armed Forces compensation scheme-compensation for the injuries they received in the Service of their country, not to provide a walk-in shower or whatever-is put in a trust that is exempt from social care cost contributions, so that it is not taken into account. That is the current situation: it is in a trust. It is a problem that is arising, and there is work in progress and we hope things are getting better rather than worse on all these issues.

Mr Burns: I think Andrew has dealt with that now.

Q523Mr Brazier: I wanted to ask a tiny question on that. Surely the solution is similar to the special arrangements we made over disregard for widow’s pensions with housing benefit. In this case we are talking about very small numbers of people nationally. Most local authorities will be dealing only with single figures, if any. So the solution would be simply to put through an exemption. It saves people having to put money into trusts and the rest of it.

Mr Robathan: That is work in progress. Discussions are going on, and that is a very good point.

Mr Burns: That is precisely what we are proposing to do.

Chair: Madeleine, do you have anything to add, or shall we move on?

Q524Mrs Moon: Only in relation to vocational rehabilitation services. Again, the Royal College of Physicians has said that the vocational rehabilitation services, particularly for those with long-term neurological problems, are patchy, to put it politely, though appalling is probably closer to the reality. That is an area I worked in prior to coming into Parliament. They are struggling now to cope with neurological injuries as a result of sports and car injuries and so on, within the ordinary population. With the increased numbers coming through as a result of those injured due to their Service in the Armed Forces, can we have some sort of commitment to an increased priority being given to those vocational rehabilitation services, so that they are available to increase whatever quality of life can be offered and built on for those who have been injured in theatre?

Mr Burns: I certainly cannot give a firm commitment today in response to that, but we will consider that whole area of care post-Murrison. You can have that commitment from me. I would also like to say, on the question of integrated care and continuity of care, which is crucial, sadly you are right. There is currently, and there has been for some time-this problem isn’t the responsibility of one Government-too much disjointed provision of care, rather than a seamless pathway.

One of the important pillars of NHS modernisation is that we seek to provide-through the commissioning process, through the public health responsibilities of local authorities, where relevant, and through the health and wellbeing boards, which ensure that the needs and requirements of the local health economy are met-a far more integrated, seamless provision of care for the benefit of the patient. That is one of the pillars that has to be achieved in a modernised NHS.

Q525Ms Stuart: That leads me very nicely to the next question, which is on the transition protocol that the Surgeon General and the excellent Andrew Cash are working on. I will bundle it up so that you know the package of the question. Do you think it is working, and what early evidence do you have that it is?

Much more precisely, Andrew Robathan keeps coming back, saying that there are very small numbers involved.

Mr Robathan: I was talking about seriously injured.

Q526Ms Stuart: Simon Burns, you referred to the new structures of the NHS. Unless I have seriously misunderstood those new structures, primary care trusts will cease to exist and strategic health authorities are on the way out, other than the three plus London, which are so big as to be-and they are going. Political accountability is through the health and well-being boards, which are very much local authority led, and the national commissioning bodies. I have a real sense that veterans’ needs are too small to register in each of those areas, unless you are now telling me that veterans’ needs will have a special pocket in the national commissioning board.

Mr Burns: No, what I am telling you is that, as you are aware, the national commissioning board will operate through a mandate from the Secretary of State. In that mandate, as well as in the NHS operating framework, there will be special reference to meeting the needs and requirements of veterans.

Q527Ms Stuart: And who is policing that? At the moment it is the health and well-being boards.

Mr Burns: It depends what you call policing.

Q528Ms Stuart: Let’s talk about Birmingham, where the QE has all these people. In Birmingham, it will be the health and well-being board, and you will not have sufficient numbers to track those people who, in all our previous questions, we said should be a priority. They will fall by the wayside.

Mr Burns: I am not as pessimistic on that as you are.

Ms Stuart: I like to trust, but I also like to verify.

Mr Burns: And I like to reassure and convince. Let’s see if we succeed.

As you know, veterans’ Armed Forces health care will be a national commissioning responsibility of the national commissioning board. The mandate that the Secretary of State gives to the national commissioning board will contain, among other things, specific reference to meeting the health requirements of veterans. The operating framework, which already has specific reference to meeting veterans’ health needs in different ways, will, one presumes, continue.

Where is the accountability? The health and well-being boards will certainly have an important role to play, because, for the first time ever, I think, we will have bodies with democratic accountability. Elected councillors will be on the boards, but there will also be others from a range of other health care provisions, plus nurses, doctors, etc. I am not convinced that the boards will be, as you said, local government dominated.

Q529Ms Stuart: No, you shouldn’t just be "not convinced". Let’s be realistic. Birmingham-population of 1 million. There will be local councillors, who will all want to be re-elected. Will the needs of the veterans be of significant weight that they will not be overlooked? You can only assure us of that if you make it part of the national commissioning requirement that every single health and well-being board in its terms of reference will also have to refer to the needs of the Armed Forces. Is that what you are going to do?

Mr Burns: The mandate will.

Ms Stuart: Each one of them will be charged to-

Mr Burns: No, there is one mandate from the Secretary of State to the commissioning board, telling it what the Secretary of State expects it to deliver for the money given to it to distribute and keep.

May I just pick up on and correct one small point? I said that the national commissioning would be done for both the Armed Forces and veterans. It is just for the Armed Forces. Veterans’ commissioning will be done at the clinical commissioning group level, where the health and well-being boards will have a role. However, I’d like to remind you that there is other accountability-that is accountability through Members of Parliament. There will still be, or there could still be in this House and another place, debates on veterans’ health or Adjournment debates on individual cases, as there are now. There is Question Time, there are written questions and so on. There are more areas of accountability.

The bottom line is that because the commissioning board will be distributing the money for the clinical commissioning groups to commission care, it will be keeping an eye on the CCGs to see that they deliver what is expected of them for the money it gives them. There will be health and well-being boards, which are there, among other things, to ensure that the needs of the local health economy are being met. There will also be Local HealthWatch, which is a new organisation.

Q530Ms Stuart: But Local HealthWatches are just about general patients. The handful of Armed Service veterans will be flooded-they will be such a small group.

Mr Burns: But veterans are also patients.

Chair: We cannot have both of you talking at once.

Q531Ms Stuart: My whole point is that in all the structures, the veterans and the Armed Forces will be such a small group that they will always be swamped by the other structures unless they are specifically teased out and given a special place.

Mr Burns: I do not altogether share that view, because I think that having a specific reference in the mandate and the operating framework gives them a degree of protection, and also, of course, there will be the JSNAs.

Q532Ms Stuart: Could you tell us what that is?

Mr Burns: The joint strategic needs assessment, which is a local assessment of the needs in the localities, which will also have a bearing on the needs of veterans in each area where there is a JSNA.

Q533Ms Stuart: Can you let us have a note on what that means? It is the first time I have heard of it.

Mr Burns: Yes, absolutely.

Mr Robathan: May I add something very briefly? There is a very real problem, although if I may say so it ties in with what Mrs Moon was saying about wanting to be slightly careful not to give undue preference, because it may lead to unhappiness among the general population-if I can put it that way. We have the Armed Forces covenant report and, notwithstanding much discussion about it, I am certain that if there were much evidence-anecdotal or hard evidence-that veterans were not getting properly treated, this Committee, among others, would have raised the point. Furthermore, we also have the voluntary sector. You would be surprised how well organised the voluntary sector is-sorry, that sounds wrong. The voluntary sector is very well organised and if ex-Service personnel go to it, as they do a lot, it knows very well how to signpost people to the right forms of treatment, to their MPs and to my office.

Chair: We will come on to that in a moment.

Q534Ms Stuart: Very quickly on the transition protocol-

Mr Burns: Can I come back on that? Can I come back on your earlier point to try to give you some more reassurance? Armed forces networks across England have been set up in recent months and that will continue. There are 10, which will broadly reflect the old SHAs plus London. One of their key jobs is to ensure that, where there are difficulties or where things plainly go wrong, whether on a collective or individual level, there are people who are named contacts who can work quickly to put things right, and access the relevant authorities or service providers to do so. I think there is a whole package of safeguards along the lines we have discussed, so if it is an individual problem for an individual person to try and cut through all the fog and actually put something right that may have gone wrong, there are these networks, which are single focus. Have I convinced you?

Ms Stuart: Not yet, but you are much further on the way than you were.

Chair: John Glen.

John Glen: My question has been answered.

Mr Havard: Are you going to ask about the rest of the United Kingdom?

Q535Ms Stuart: Yes. I still want to come back to them about the transition networks and whether they think the transition protocol actually works.

Mr Robathan: Yes, we do, and we are piloting schemes.

Mr Burns: Just to reinforce what Andrew Robathan is saying, we are working very closely with the MoD, because, as you know, the schemes are very new-in their infancy-and being piloted. We want to ensure that they will actually be in such a place that they achieve the aims designed for them, and that the care of an individual is prepared in advance of discharge. It is a little premature to get a proper view, but I am pleased at the way it is going so far.

Q536Mr Havard: Well, that was a jolly interesting interchange about how you are going to do things in England, because you appear to have some problems; but there we are.

Compliance, however, is a very important issue as far as the whole of the UK is concerned, but more important is some sort of consistent application of the obligations that are in the covenant for this to happen, because people may currently live in England, then move to Wales, go to Scotland or whatever. So it is not just about the English health service, and things are done differently. The transition protocol, for example, is done partly through this concordat between Wales and the MoD for health service delivery. The veterans’ services will be done in a slightly different fashion, and so on. So there is a variable geometry, as it were, around the United Kingdom. How are the obligations within the covenant going to be properly and consistently monitored and applied in these areas, across all the different health services that now make up the United Kingdom?

Mr Robathan: If I might briefly say, before going on to health service issues, that I have recently received letters from both the Welsh Government, or the Welsh Assembly or whatever they call it-

Ms Stuart: Welsh Assembly Government.

Mr Robathan: Thank you. I have received letters from them and from the Scottish Government, who have both welcomed the covenant and welcomed the community covenants-

Q538Mr Havard: Well, we know you haven’t, and we are asking questions ourselves about why you haven’t.

Mr Robathan: You know that we haven’t, and so do I. In Scotland and Wales, they are certainly of the same intention as us, but of course devolution involves different decisions sometimes being taken in different parts of the devolved Administrations. We are keen, however, that everybody should get the same good standard of treatment. On the NHS side, I will hand over to Simon.

Mr Havard: Before you do, Simon-

Mr Robathan: I have just been told that the transition protocol has been agreed with all three devolved Governments, including Northern Ireland.

Q539Chair: The answer that you have just given implies that the priority for veterans is a matter of discretion in the devolved Administrations.

Mr Robathan: No, I think the manner of implementation, depending on what is devolved, is to a certain extent-I will let the health service answer on this-and they may do things in a slightly different way, because that is the nature of devolved government.

Q540Chair: So the priority remains a national priority even though its implementation in devolved Administrations may be differently handled. Is that correct?

Mr Burns: If you are talking about health, when I come to answer, I would like to answer in my own way to get the wording right for the Department of Health and our focus on health care throughout the UK.

Chair: Would you like to do that now?

Q541Mr Havard: Before you do, you talked about a Cabinet board-is that what you said?

Mr Robathan: I don’t think I mentioned a Cabinet board. Perhaps it is my bad pronunciation.

Q542Mr Havard: Let me ask the question then. Who in the Ministry of Defence is going to measure and ensure that what you believe is a consistent application is in fact a consistent application?

Mr Robathan: Some matters will obviously come to us. The Ministry of Defence will be able to look across the board-I must not use the word "board". The MoD will look across the country and the covenant report will of course cover other parts of the country. My point is, Mr Havard, that we have devolved Governments. Whether we are particularly keen on them or not, we have devolved Governments, so that is the situation that we are in, and we therefore need to work in co-operation with those Governments. They may be of varying political hues, but we are working in co-operation with them and they agree on the way forward. We have received agreement on the transitional protocol and we have received letters in the last month or so from both the Scottish and Welsh Governments about the community covenants, which were part of the Strachan report late last year.

Q543Mr Havard: In the MoD, are you the person responsible-

Chair: Order. We need to pick up a bit of speed.

Mr Havard: Are you the person responsible for ensuring that that happens? Who in the MoD looks across the piece to ensure that the obligations of the covenant are being properly applied with all these other organisations?

Mr Robathan: The Secretary of State will produce an annual report to Parliament, which I am sure this Committee will examine. It will therefore be his overall responsibility, but in the day-to-day administration it is delegated to me.

Q544Chair: Now, Simon Burns, you were going to answer in your own words.

Mr Burns: From our experience of dealing with the devolved Governments-we have dealings across the whole health spectrum with health Ministers in Wales, Northern Ireland and Scotland-we have found that it is an effective relationship. To meet the needs of the Armed Forces in specific as opposed to other health issues, we have got an MoD-UK Departments of Health Partnership Board, the purpose of which is to share information.

If we decide to implement a policy such as the Big White Wall that was announced in England today, we will share with the other UK Governments what it is, how it works and how it has been put together-all the nitty-gritty of it. It will be up to them whether they want to implement the same sort of service for that target group. Obviously, because of devolution, we cannot force them; it is up to them. The partnership board will provide them with all the information-the analysis of what we think can be achieved and how it can benefit those it is targeted at-and they will take a decision. Delivery may be different between the four parts of the UK, but there is a single united focus to provide the best possible quality care.

Q545Mrs Moon: One area we need to look at is in relation to-again-mental health problems. In your exchange with Gisela, there was a suggestion that the numbers coming through were going to be small. The Murrison report points out that 24,000 people leave the military every year; at least 10,000 have been on operations; and the 58 English mental health trusts would expect to see at least 413 patients a year, which is a not inconsiderable additional number. Two issues have been raised. I may have misunderstood this, but I think there was a suggestion that there is an offer that people can be followed up for one year after leaving.

Mr Burns: Through the NHS, the Department of Health offers a service for the first year that someone has left the Armed Forces. They can be followed up if they wish to be, just to check if they are all right, how they are feeling and whether they feel they need help or access to treatment. That is totally voluntary because, as Andrew Robathan said in an earlier answer, a number of people leaving the Armed Forces do not want to be followed up or to have any contact with what they consider to be "the authorities".

Q546Mrs Moon: I understand that. I would like to go very quickly into two issues. First, I have a post-traumatic stress disorder group in my constituency that is funded by the British Legion. One of the major complaints of those who left the military with mental health problems is that they felt abandoned when they left. How will you ensure that they no longer feel that abandonment, given that they may also have some resentment to being followed up?

Secondly, how do you ensure that those who leave their Services, and are perhaps a little worried as time goes on about how they are coping and whether their mental health is beginning to deteriorate, have access to the equivalent of something like the Big White Wall, which is an incredible move forward? If it operates and works successfully in mental health terms, it will be a dramatic change in mental health service provision. How will you ensure that those who go into the devolved Administrations also have the opportunity to come back and to utilise that service, which, as I understand from what you said, is going to be only English-based?

Mr Burns: On the general issue of the provision of mental health care for veterans and how veterans can access it, there is a problem in this country across the range on mental health issues.

Q547Mrs Moon: That is why I am particularly concerned, because of the rising numbers that this would produce.

Mr Burns: We have suffered for far too long with mental health in general being a Cinderella service of the NHS. It has been the service that no one wants to talk about, including sufferers and their families, because of the stigma that is unacceptably attached to it. If you suffer from mental health, you are not treated in the same way as if you have appendicitis-there is not the sympathy, and even the patients and family members often do not want to discuss it, because they are either ashamed of their or their family member’s condition or they are frightened of the reaction they will get from other people.

Frankly, what we saw from the Major Government and, to their credit, the Blair Government and the Brown Government, was not only a significant increase in the funding of mental health services and a deliberate policy to increase and play catch-up-although one can argue that there should be even more-but also deliberate attempts to break down the stigma attached to mental health. Sadly, particularly on the latter, there is still a long way to go, but there have been great strides in the 14 years of the Labour Government and under the Major Government, and that is continuing under this coalition Government.

In that context, there have been a number of initiatives so that veterans and their families can access help. One of the ways that will happen, as for anyone else, will be through their GP making referrals on their behalf to the most appropriate place to go to for help, depending on their medical condition or problems, and through the mental health community partnership.

We have targeted veterans in particular, because next year we are going to implement a veterans information service, which is for Service leavers. It will give them help, advice and information about their health and well-being. The Big White Wall, which I keep mentioning today, is a service for them-and their family members, who are equally important.

There are also services like the 24-hour helpline, which is delivered, and up and running. It has had about 3,000 calls to date on its freephone number. There are non-specific helplines and access, such as NHS Direct and NHS 111, which is being piloted at the moment. A Royal College of General Practitioners e-learning tool is being launched today, which covers many of the concerns that are raised by family members and veterans about mental health.

So a package of help is provided in different ways. Help is targeted on a voluntary basis, so veterans and their family members can access the service if they want to. There is also the traditional and more conventional way of going to see your GP if you believe that there is a problem, and then accessing the relevant NHS help. Mental health care is provided in other ways at the more extreme end when people get into significant problems in public, at which point the mental health Acts come into force.

Chair: We move on to services that support families-those who are bereaved or those whose family member has been injured.

Q548Sandra Osborne: Does the MoD recognise the long-term needs of families who have been bereaved or whose relative has been seriously injured?

Mr Robathan: Yes, we do. Each individual case is different, but each one is tragic. One of the aspects of my job is seeing, occasionally, bereaved families who have an issue to raise, and, frankly, it is pretty heart-rending. We can never do enough, and in each case people will move in different ways.

We have talked about long-term care of those who are seriously injured, but there are various issues for the bereaved. As I said, we have been getting better and better for a number of years. We have family activity breaks, which, I think, are open to bereaved families and families of the injured. We have access to counselling, and an organisation called Cruse will also counsel families. As you know, the Prime Minister has announced that there will be university scholarships to pay the fees-which, as we know, will be quite a lot-of the orphaned children of Servicemen. Those who are bereaved can retain their living quarters for two years or more while further arrangements are being made. In conjunction with the RBL, we provide the Independent Inquest Advice service for bereaved families.

You can never do enough. These are awful cases-many of them are tragic. But we are getting better and it is important that we continue to do so-and learn. Yesterday, I was talking to someone who was suggesting how we could improve the making of wills by Servicemen. One problem is that when people are killed in action, although they will have had all the necessary advice-Bob Stewart will know this-they will not necessarily have made a will. We cannot compel them to do so, but we can encourage them even further.

Q549Sandra Osborne: In relation to the particular needs of children, any problems often manifest themselves in the classroom. Have there been any attempts to educate teachers and the education system in general about bereaved children’s needs?

Mr Robathan: You may have come across an organisation called the Directorate Children and Young People, which is down in Andover. It is responsible, among other things, for service education, and it used to be part of what was called "Service Children’s Education", or something similar, but is now the Directorate Children and Young People. That organisation is closely involved with supporting children and young people, particularly when their parent has been killed in action. That is one of its focuses, besides the broader education system-indeed, it also deals with situations where a parent is medically discharged after an operational injury.

In a broader sense, there is a £3 million fund that schools and local education authorities can apply to for schools with a large number of Service children. Of course, there is also the pupil premium for Service children. For bereaved children, I have mentioned scholarships, and we also work closely with the charitable sector-SSAFA, in particular, and the Child Bereavement Charity, to ensure that Service children, of both the injured and killed, are given as much help as possible.

Q550Sandra Osborne: I ask the Health Minister the same question, in relation to GPs and other health professionals. Are they conscious of the problems of bereaved families in the longer term? Can they point them in the right direction so they can get adequate support?

Mr Burns: I certainly believe that most GPs know how to point a family in the right direction for appropriate help and counselling. Because GPs also provide that service for people who have nothing to do with the Armed Forces, many of them will be familiar with the right way to go. That does not mean to say, however, that one can relax and take it for granted that everything is fine. One has to ensure that GPs are cognisant of the best way to look after their patients, and that they can point them in the right direction.

Q551Chair: Moving on to the relationship with the charitable sector, the Ministry of Defence, in its memorandum, said that there has been a step change in the amount of funding from the charitable sector. Andrew Robathan, do you think that the Ministry of Defence is spending that money well, and is there any suggestion that money provided by the charitable sector is now going on things that would previously have been considered the responsibility of Government?

Mr Robathan: On your second point, it is important to realise that it is not new for the charitable sector or the voluntary sector to be involved in providing assistance with, for example, casualties from wartime. There is a fantastic house-I think it was called the Erskine estate, but Sandra Osborne might know-on the banks of the Clyde. It is now the Mar hotel, but I think the estate was gifted as a charitable institution for injured Service personnel after the first world war. Headley Court itself is a charitable trust that was given to the nation.

The voluntary sector’s involvement should be applauded. What it really does is provide assistance, and such things would not necessarily be done so well or so thoroughly otherwise. It is almost about luxuries on top-not luxuries; it is the additional bonus on top. I do not always believe, and this is because I come from the party that I do, that the dead hand of the state is the best way to run all such provision. The voluntary sector should be applauded, but that does not exempt the state from its responsibilities at all. There is a balance to be struck, if I can put it that way.

On spending, I think what you mean is running things that are provided by capital grants.

Q552Chair: For instance. That would be one question.

Mr Robathan: Well, a particular example recently was the £11 million that was spent on the swimming pool at Headley Court. I think you have all seen it. It is a fantastic facility, with a floor going up and down, and gymnasium facilities, too. It is very good, and was provided by Help for Heroes. Before we were given that-it was under the previous Government-there was a proper discussion to ensure that we could afford it, and that we would have the funds to run it. We do. We will only take on a project if the running costs are affordable and sustainable. That is a particularly good example, which I think you have seen.

Q553Chair: If smaller charities want to offer innovative services to the Ministry of Defence, how would the MoD evaluate them and allow them a foothold in working with Service or ex-Service personnel? I can give you an example, which you no doubt know, which would be Resolution.

Mr Robathan: Sorry?

Chair: Resolution is an organisation which, I think, feels slightly squeezed out of the Ministry of Defence’s attention. It provides help in the mental health arena and it feels that the Government, like the larger charities, only consider the rather more conventional approaches to dealing with mental health issues.

Mr Robathan: This is PTSD resolution?

Chair: That sort of thing, yes.

Mr Robathan: First, those working in the charitable or voluntary sector are doing a fantastic job. They should be given all credit. Not every organisation is as good as others. We must accept that. But I take the view that we should not be prescriptive. If people wish to set up a charity to do something, they almost invariably have our blessing. But we will only support, especially in the medical field, which you are investigating, NICE-accredited clinical interventions. Quite a lot of people come forward suggesting that they can do this, that and the other. Our advice, especially in the mental health field, is that it is not necessarily the case. Much of this intervention is well intentioned, but we have a responsibility only to support those that are NICE-accredited. I think you would accept that.

We welcome the charitable sector. There is a proliferation of small charities. Sometimes small local charities make good local links, but you will know the work of COBSEO to try to bring together charities, which is excellent. I see them quite often. As I said, it is not for us to be prescriptive. The outstanding example in the charitable sector is Help for Heroes, which four years ago did not exist. In four years it has raised £100 million and more. I pay great credit to Bryn Parry and his wife Emma for doing that. When they came on the scene I understand they were not particularly welcomed by some others who said, "You just fit in with whatever we are doing in the bigger charity world." He said, "No, we want to do this" and they have achieved remarkable things.

Q554John Glen: The other thing that Bryn Parry mentioned last week was the lack of a speedy response from the MoD. One of the issues we were looking at was the whole issue of masses of capital investment setting up ongoing running costs and a clear delineation of what the MoD should provide and what liabilities would be taken on by ad hoc investments in the short term. There was concern about whether, when the income flows perhaps diminish in a few years’ time, the running costs that have been set up with these capital investments will be properly accounted for in the planning.

Mr Robathan: That is a very good point because we are not talking about just this year; we are talking about decades, and perhaps further. I used the illustration, and I will stick with it if I may, of the Headley Court swimming pool. There is an agreement that we will run it for as long as Headley Court is there and open.

Q555John Glen: Is that more broadly enshrined in policies and processes?

Mr Robathan: Yes, for instance there are the Army personnel recovery centres, which you will know about; Tedworth House down in your neck of the woods, Chairman, is being set up by Help for Heroes. Its running costs are going to be paid jointly by the MoD and the RBL. The British Legion is paying most of the running costs but we will be very heavily involved. It comes down to protocols and agreements, which are quite formalised for good reason. Sometimes, with very good intentions, charities fail. They try hard and they fail. We are not prepared to take on the responsibility for all charities. I was asked to take on responsibility for a charity that we advised we would not support financially. It came to us for financial support and we said that we could not do it and you will understand why not.

Chair: Finally, future challenges. Gisela Stuart.

Q556Ms Stuart: May I start with health? Simon Burns, when we went to Walter Reed and we asked them what their biggest worry was for the future, they said that it was mental health. As far as you are concerned, what is your biggest worry for the future, in the context of the military covenant and the Department of Health?

Mr Burns: The biggest challenge, rather than worry, is that we have to ensure that the Department of Health and the NHS focus and improve on outcomes, because outcomes are the most important thing to the individual when they need treatment. For those who are injured, we have to ensure that the outcome is that they can return to as normal a life as possible as quickly as possible, having had the finest care available. If, as a result of their injuries or their condition, it becomes a long-term condition, we have to ensure that they have integrated and seamless provision of care. That is the challenge. I phrase it more positively than calling it a worry, which would be more negative.

I believe-I suspect, with all due respect, that you will disagree-that the modernisation of the NHS will help that, because the NHS is by definition an evolutionary body. It is also a crucial challenge that we ensure continuity of care. That is essential and uppermost in the needs of patients. It is crucial that they are able to make the transition from Service to civilian life, which is challenging in itself, let alone if you have a medical condition or a disability or whatever. We have to work together to ensure that the needs of each individual are met to the highest possible standard. That is where the Armed Forces networks have an important and crucial role to play, because if something goes wrong, they provide a point where someone can go to someone who can make the necessary phone call to sort it out as quickly as possible, rather than them getting into a backlog where it will be dealt with in due course. At the point where someone accesses a network, for them it has become a crisis or it is uppermost and urgent in their mind. They will want action, and they will probably want it now. That is why the networks are so important.

Q557Ms Stuart: And the Armed Forces network will also encompass social care?

Mr Burns: Yes, it is a complete package, from different facets of input, whether the health service, the military, the PCTs now but CCGs next and others in respect of social care.

Finally, so I can shut up, it is important that the hard work being done at the moment will put in place processes for the transition of seriously injured personnel. The urgency of awareness-raising and the identification of the needs of veterans that is taking place for good and obvious reasons has been highlighted over the past few years because of what has been going on in Afghanistan and Iraq. We have to make sure that that continues afterwards and that everything that is being done at the moment does not come to a jolting halt as soon as we discover that we are not in conflict somewhere around the world. It has to be sustainable long term because from a health point of view, sadly, the injuries, needs and requirements of too many people will not end the day that we cease having a presence overseas in a war zone.

Q558Chair: I am very pleased that you made that last point. Andrew Robathan?

Mr Robathan: He has really made my point for me. I would only add that, as the Minister in charge of ex-Service personnel and veterans, this is a long-term challenge. It will continue to be work in progress as medical technology improves, because the care for these brave, young men will go on for 30, 40, 50 or 60 years and we need to be clear that our responsibilities towards them remain. That is why we have pretty good co-ordination between the Department of Health and the MoD, and across the Government. This continues to be work in progress, but it is very important that we get the co-ordination right. People will inevitably fall through the floorboards from time to time, but we need to make sure that we are there to help them-with, indeed, the voluntary sector.

Chair: We are done. Thank you both very much indeed for coming to give evidence and thanks to your supporting teams behind you.